Accessibility
Affordability
Access treatment • Access to healthcare services has been impacted upon by recent austerity measures: staff and the number of healthcare facilities have been reduced, especially outside cities.6 o The collected evidence suggests that physical access to pump therapy is an issue (only available at hospitals; long waiting lists), especially for people living further away from a healthcare professional.5,6 o The survey findings also suggest some difficulties in accessing education and information, especially in rural areas.5,6 o Misinterpretations and misunderstandings of regulations – the application of certain fees to consultations and medical transport – are also creating further challenges to access to healthcare (see also Affordability)6 Stock and shortages • The small number of stock issues reported do not seem to have significant disruptive impact on people’s treatment.6 They appear to remain localised problems6 and people reportedly are able to find alternatives within a few days.5 o As mentioned above, stock issues are a problem at the dispensing level, which seems to have difficulties being supplied.5 o Delays in supply, costs-reduction measures leading to lower stock levels and parallel exports – especially for insulin – have been cited as potential explanations.5,6
PORTUGAL Looking ahead Entitlements and coverage for diabetes supplies appear to have been mostly kept unchanged so far. However, the impact of austerity measures on healthcare services is making access to these products more difficult. Additionally, these austerity measures are impacting on access to new technologies for diabetes (not included in this survey), which are not covered by the NHS.6
• Public coverage of diabetes products has been kept unchanged for the most part, despite austerity measures. However, financial hardship at the individual and household levels due to the economic crisis is converting pre-existing co-payments into a major challenge for certain people with diabetes – especially low-income groups.6 o According to collected responses,5 the median out-of-pocket payment for diabetes medicines and medical devices per month was EUR 23 (USD 29), or EUR 272 (USD 353) per year. This makes up 2% of the Household Net Adjusted Disposable Income – or as much as 5% for the poorest 20%. o Newly imposed fees for healthcare – from which, diabetes-related services are supposedly exempt – are adding to the financial burden due to diabetes, related to co-payments on diabetes supplies.6 o Certain medicines and devices have benefited from price reductions negotiated with the industry (see below).6,8 • The choice of brand is left to the prescriber, as most diabetes supplies on the market in Portugal seem to be branded products.5,6 Substituting a medicine is possible only when a non-branded product is available.3,6 o For pumps, the choice of brand is also constrained by public tender: only one brand per category (see Availability) is provided free of charge.6 • The prices of certain medical devices are set through the public tender process.6 The prices of reimbursed medicines are set by the Ministry of Economy, using external reference pricing.9 Caps are placed on the mark-ups applied by wholesalers and pharmacists. A reduced VAT of 6%8 and another special tax4,9 are applied. The Ministry of Health may also negotiate further discounts with the industry.7 o With the economic crisis, Portugal has been among the EU countries bringing the highest number of changes to its pharmaceutical policy. The price of medicines has been reduced; discounts for the NHS have been negotiated with the industry; reference-pricing methodology has been changed; margins, the VAT rate and certain co-payments have been revised.8
Financial coverage The Ministry of Health decides on whether a product should be covered and at what rate.3,4 For medicines, the decision depends on the therapeutic value of the medicine and its price. People with diabetes, like people with other chronic conditions, are exempted from co-payment on certain medicines.3 Other medications are classified into categories with different rates of reimbursement according to their therapeutic value. Reimbursement rates are based on a reference price (the difference between the reference price and the retail price is paid out-of-pocket by people with diabetes).3,4,9 Medical devices apparently follow another scale.
88
Insulin
Free1,5,6
Anti-diabetes medication
Partially covered5,6
Medication for hypoglycaemia
Depending on the type of medicines, partially or not covered5,6
Pens and related supplies
Free1,5,6
Syringes and needles
Free1,5
Pumps and related supplies
Free (see Availability for criteria)5,6
Blood glucose test strips
Partially covered5
Glucometers
Free5,6
Ketone test strips
Partially covered5
Please note that the information provided above only present a summary of the reimbursement system and may not apply to individual cases.
References 1 EURADIA, FEND, IDF, & PCDE. (2011) 2 Global health observatory data repository. (2013) 3 Barros, P., Machado, S., & Simões, J. (2011) 4 PPRI & WHO (2011) 5 IDF-Europe Access survey (2013) 6 APDP (personal communication) (2013) 7 Torgal, J. (2011) 8 Vogler S. et al., (2011), Southern Med Review 9 Teixeira, I., Vieira, I. (2008)